‘SLOW MEDICINE’

San Franciscan Dr. Victoria Sweet’s passion to reclaim the ‘magical,’ often spiritual doctor-patient relationship at the heart of true healing

February 22, 2018 Araceli Martínez

When Dr. Victoria Sweet arrived at Laguna Honda Hospital in San Francisco one day in 2007 and saw trucks and equipment preparing to bring down the site where she had practiced medicine for more than 20 years, she knew that the project to demolish the old building and put up a new hospital would change her life.

She decided it was time to tell the story of the old, almost monastery-like Laguna Honda and the lessons learned about what it takes to truly care for human beings.

“I realized that once the hospital was closed and torn down, nobody would believe what had happened there,” she said in an interview with Catholic San Francisco. “No one would understand it.”

Sweet, now an associate clinical professor of medicine at UC San Francisco, decided to write a book “and capture what I learned so other people could experience what I experienced.” Five years later, in 2012, she published “God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine” (Riverhead, 2012). Her second book, “Slow Medicine: The Way to Healing” (Riverhead, 2017), came out last October and earned her national reviews as a “visionary” and “subversive” naming the economic and human costs of an efficiency-centered health care status quo.

Reviewing the book for Catholic News Service, Rachelle Linner said “Slow Medicine” “is imbued with a vocational sense of medicine, of the spiritual ground of being a healer. More than once Sweet reminds us that, in the Middle Ages, ‘nursing and doctoring were done by nuns and monks as a calling.’”

Although not Catholic, Sweet is inspired by Catholic ideas of beauty and spirituality.

Dr. Victoria Sweet is pictured outside Laguna Honda Hospital in San Francisco, where she practiced medicine for 20 years and was inspired to write a book about her insight that it is not technology or efficiency but rather the doctor-patient relationship, including unhurried time for observation and for both people to get to know one another, that is the key to quality health care. (Photo by Dennis Callahan/Catholic San Francisco)

Catholic inspiration

“For some reason, Catholicism has always touched, moved and inspired me,” she said. “In particular, medieval Catholicism, and even more particularly, the medieval Catholicism of 12th-century France. There’s something about its clarity, its beauty: Anselm’s ‘God is a circle whose center is everywhere and whose circumference is nowhere,’ for instance.

“Which is why, doubtless, that Hildegard intrigued me from the beginning, and why, when I found out that I could walk the medieval pilgrimage route through France to Santiago, I just had to do it,” Sweet said, referring to the 12th-century German Benedictine abbess, composer, visionary and doctor Hildegard of Bingen. “And it was worth every step, spiritually and morally.”

If modern medicine fragments the body into parts, Hildegard saw the body holistically. Her vision led Sweet on a search for the contemplative roots of what she would call “slow medicine.”

“Could it be the missing piece of Western medicine?” she writes. “The one that explains what I had been seeing all these years that didn’t fit?”

Sweet could not have imagined that her first book, “God’s Hotel,” would have a national impact, contributing to a debate on the changing – and not for the better – relationship between doctors and patients in an era of high-tech medicine and soaring health care costs. The demolition of the old Laguna Honda, a throwback to a far slower and simpler time when “God’s house” with its promise of care for body, soul and spirit was synonymous with hospital, symbolized that change for Sweet.

Sweet tells some of the most meaningful stories she experienced with her patients. She also narrates the transformation that Laguna Honda underwent over the years in its administration and medical practice.

A fourth-generation San Franciscan, Sweet majored in mathematics at Stanford and minored in classics. Her academic interests, which informed her later vision of what a good doctor can be, balance science and the humanities.

She started on a doctorate in psychology at Harvard but realized that medicine was her calling. While working at Laguna Honda, she completed a Ph.D. in the history of medicine, discovering what would become the title of her first book when she learned that “God’s hotel” or “God’s house” used to be what a hospital was called in France.

The old Laguna Honda, with its space for relational, humanistic medicine, was such a place of healing when Sweet worked there.

“‘God’s Hotel’ reminds us of the kind of doctors that we do not see much anymore,” Sweet said. “We used to have very human doctors, those who went to see sick patients at home. Why is the reason we no longer have this type of doctor? Is it the economy? Budget problems? Changes on public policies?”

The change has not come about by accident, she said with passion.

‘Deliberately engineered’

“It was deliberately engineered in the 1970s,” Sweet said. “Before 1975, a doctor had a code of ethics. It goes all the way back to Hippocrates when the main thing for a doctor was to put the patient first. And when you went to medical school, you would swear that code. And there was a code of ethics that the American Medical Association had. In 1975, the Federal Trade Commission sued the American Medical Association and said that was actually illegal to put patients first. The American Medical Association went to the Supreme Court, and in 1982, the Supreme Court ruled that medicine was just an industry, a business, not a profession. The AMA lost in 1982, and by 1983, the fast-food industry, all those kinds of industries, were buying hospitals and urgent care clinics and basically taking control of medicine. And that’s why we’re in a big mess. It’s not about the budget. Before that decision, health care took 10 percent of the gross domestic product. Today it almost takes 20 percent, so it has not saved money. It costs a huge amount of money. It is a huge way to make money.”

Anyone who wants to make money in health care today should become a manager, not a doctor, she said.

How can medicine recover some of its spirit of humanism?

Sweet said many doctors who don’t want to work in the health care industry are opening offices and visiting patients.

“There are many doctors who have found a solvent way to do it,” Sweet said. “In the last five years, I have known doctors who are doing this very successfully and charge patients by the hour and drive to see the patient at home.”

Such personal care is relatively expensive, but much less expensive than if the patient has to go to an emergency room.

“Some doctors have started a concierge practice where the patients pay a monthly amount of money, sometimes $100, sometimes $500 a month. But with that, the doctor doesn’t have to work for anybody else.”

Sweet said she has a doctor that has her own practice and makes home visits.

“The last two times I got sick, she came to my house. And I didn’t have to go to the emergency room. That was the end of that. So I did end up saving money in the long term.”

For Sweet, most doctors are fundamentally compassionate and many are quite spiritual because they see people die, nearly die, get sick and recover. They see miracles and disasters. She believes that doctors could become spiritual and more compassionate if they had the time.

‘Just horrible’

She said most people in health care now spend most of their time on their computer, rushed and harassed. This “just horrible” environment is one reason she is not practicing medicine now.

“After writing my first book, I looked around to find a different kind of place to practice and every single one just showed me that I will be spending my time in a computer,” she said. “I didn’t want to be in that position.”

At Laguna Honda, much of her medical learning was through observing patients. Observation combined with the doctor-patient relationship is key to healing, she states in “God’s Hotel.” That was how medicine was practiced during her years at the old Laguna Honda.

“I worked in a place that looked like a medieval hospital, a very old-fashioned hospital, like a monastery and a church,” she said. “Most of the time, we had almost 1,200 patients. Sometimes they stayed for months and years.”

Sweet had enough time to talk with her patients and get to know them.

“It was not just talking to them but, even more important, to examine them myself,” she said. “Not in five minutes but really it takes about an hour to really examine a patient. The exam alone tells you a huge amount about what’s going on. It’s just crucial to do that. And then after that, I had the time to know the family, get the old records, talk to the old doctors that they have to take care of. And I had the time to try different things.”

The right diagnosis is not always obvious, Sweet said. Sometimes she found that patients did not need all the medicines they were taking.

“I had the time to try things, to stop others,” she said. “And what impressed me was how efficient it was and how much money I saved by having that extra time. And I will give an example. Most of the patients I met for the first time were very sick for a long time, and most of them, on average where on between 15 and 26 medications. Most of them only needed three or four of these medicines but no other doctor had the time to go through and find out, try this or take them off. It was just amazing because most of the patients only needed a few medications. And the amount of money saved when you take someone out of 10 or 15 medications is enormous. The patient gets better.”

She also realized that there was a kind of magic involved in the process.

‘Something magical’

“I would sit on their bed and they just got better and better; and I got better in some fundamental way about my relationship with the world,” she said. “I started seeing we were all in this together and when you have that, something magical happens. It’s just sweet, beautiful and meaningful.”

Medicine works best, Sweet said, with the best possible diagnosis and treatment for the least amount of money, when it is personal and face-to-face, and when the doctor has enough time to do a good job and pays attention not only to the patient but to what is around her.

Sweet, who was awarded a Guggenheim Fellowship in 2014 to work on her second book, calls this approach “slow medicine” and believes that putting this into a wider practice would be beneficial and satisfying for patient and doctor, and less expensive for everyone.

The New York Times called her ideas “hard-core subversion.” Vanity Fair noted her “radical and compassionate alternative to modern health care.” Health Affairs has described Sweet as a “visionary” and “subversive in all the best ways.”

Sweet described her second book as a slow-medicine manifesto disguised as a memoir.

“After writing ‘God’s Hotel,’ I’ve been going around speaking all over the world for the last five years. I got emails from people from everywhere who told me that this idea we are talking on about what a doctor really should be, it’s disappearing. In ‘Slow Medicine’ I decided to tell the story that really influenced me and affected me and created me as the doctor I am today.

“These stories I tell in ‘Slow Medicine’ are not the same as those of ‘God’s Hotel.’ ‘Slow Medicine’ is very much about before I got to ‘God’s Hotel’ but it is also a little bit during ‘God’s Hotel’ and afterward,” she said. “It’s kind of like a prequel and a sequel to ‘God’s Hotel.’ You will find out in a more explicit way about the relationship between doctor and patient. Examining the patient, listening to the patient, having the time to be a human being.”

Asked in an email what health care consumers can do to ensure better care, Sweet bridled at the label.

What patients can do

“I believe, for starters, that this metaphor is pernicious, and we should avoid using it,” she said. “I make this point very strongly in my new book. Patients are not consumers, but sick, scared, vulnerable. Doctors and nurses are practicing a calling, a vocation, a craft and an art. What can patients do in the current climate? I wish I knew. I see medical care being run over by the steamroller called corporate profit, and the media being remarkably complacent until they themselves get sick. Even as I write this, there are several enormous hedge-fund led mergers of the health care system taking place, with no one noting. Patients should expect more from their doctors than sitting in front of the computer. Patients should expect and demand that at the very least their doctors look at them, examine them, think about them.”

Although she wrote her second book as a medical memoir, she pointed out that it is not only about medicine.

“It’s about where the whole world is going with writing, education, with almost every facet,” she said. “We are forgetting that there is something so important in this personal relationship between people.”

EXCERPTS FROM ‘SLOW MEDICINE’

On her elderly father’s hospitalization

“’You’ll get out of here, but it’ll take a while. The main thing is, when they come in and ask you the date and the place and the president, stop telling them it’s Millard Fillmore. They don’t know who he is, they don’t realize you’re joking, and they think you’re crazy.’ He looked up at me, his blue eyes still capable of twinkling. ‘Okay.’ Although, as I would see when I later went through his electronic health records, no one did come in and ask him the date, the place, or the president. Every single person – hospitalist, nurse, therapist – simply stood in the doorway, saw old man unshaven and tied up, and checked the box labeled ‘Confused.’”

“Everything looked so good in the computer, and yet what father had gotten was not medicine but health care – medicine without a soul. What do I mean by ‘soul’? I mean what father did not get. Presence. Attention. Judgment. Kindness.”

‘Prayer works’

“And just as Dr. Greg taught me to know what I didn’t know, and Marcela that sometimes I wouldn’t even know what I didn’t know, Joey taught me there was more to be known in heaven and earth than is dreamt of in our philosophies. Such as prayer. Prayer worked, at least that once and maybe sometimes and maybe always. How it works, who knows? It changes the tempo somehow, bends space-time perhaps, so that instead of things going one way, they go another. Or it makes people more attentive, starts a basso continuo in the background that tunes our seventh sense of awareness – even if you’re not the one doing the praying, simply a bystander, two people removed.”

Rule of thirds

“The door of the elevator opened and he [Dr. Greg] stepped in. But he held it open for a moment.”

“’We doctors think we’re so important,” he told me, “but the way it works is that in any disease about a third of the patients get better, a third get worse, and a third stay the same – and all we do is change who does what.’

“Then he let go of the elevator door and it closed and I never saw him again. But his words would resonate with me for the rest of my life.”